The Problem With Traditional Diagnostic Labels

by Stanley I. Greenspan, M.D., Addressing the increasingly common use of labels for children with special needs.

Teachers and parents are frequently presented with bewildering diagnostic terms as well as more disturbingly familiar ones, such as mental retardation and emotional disorder. Often left to figure out the implications of these labels, adults must act on their impressions about whether a child with a particular diagnosis can be helped and, if so, how.

Looking Closely at Labels

Traditional diagnostic labels have served several important purposes: They have helped professionals keep track of the types of problems children are having and helped researchers study the causes of and some treatments for those problems. But diagnostic labels also have significant limitations. First, in trying to group different individuals together under a large category of what they appear to have in common, we risk grouping together children who are actually quite different from one another.

A clear example is the attention deficit hyperactivity disorder (AHDH) label. The ADHD diagnosis focuses on the similarity among children who are inattentive, perhaps also overly active, and maybe unable to concentrate well enough to follow directions. By settling for the label ADHD to explain the behavior of such children, we underemphasize many important differences among them. One child may be inattentive because he can't plan or sequence his actions well. Another may have great trouble processing incoming information. Yet another may be oversensitive to sound and, when confused, become inattentive and disruptive. A given child may be hampered by a little bit of all of the above while another suffers from none of them but, instead, is restless and very anxious for psychological reasons. You can see that these are quite different origins for seemingly similar behavior. Each calls for a very different intervention. The danger of using the labels is that the uniqueness of each particular child is lost. Settling for the labels often becomes more confusing than helpful.

Building Individual Profiles

How, then, may we categorize special needs children in a manner that allows us to do research and have a better understanding of their common problems while at the same time arriving at effective individual treatment strategies? True understanding and effective intervention demand that we focus on the uniqueness of each child rather than group many under some broad category of common behavior.

There is undeniably a great deal of pressure, in the wider culture and within the professions, to use the traditional ways of categorizing special needs children with diagnostic labels rather than the method of so-called dimensional approaches, which we prefer. We choose to look at certain dimensions of each child, such as the ability to communicate or relate. In other words, ours is an approach that allows consideration of the unique profile of each child, in terms of the way he or she processes sensations, including sights, sounds, and touch, and the way he or she plans and carries out actions.

Another problem with traditional labeling is that it often omits a consideration of where the child is developmentally. In contrast, our profile includes each child's functional level of emotional, social, and intellectual development. Interactions with family members is another important component of this individual profile. Together, these several descriptive pieces enable a teacher and parents to carry out an intervention plan designed specifically to meet the individual child's needs. The approach helps us to understand the processes underlying the challenges of a special needs child and enables us to go straight to the heart of each child's ability to think, feel, and interact in order to improve whatever needs improvement.

Sometimes a teacher tells us that she has a new child in her classroom who is autistic, and she wants to know how to work with an autistic five-year-old. Or she spots a child who she thinks "has ADHD" and asks how to help him. We explain to her that we can be much more helpful if, instead of using a label, she tells us that the first child seems indifferent to other children and engages in solo repetitive play rather than typical interactive dramatic play or that the second child finds it difficult to pay attention when there's a lot of peripheral noise or when the teacher gives a lot of oral instructions or asks him to do a task that requires many steps.

If the teacher spells out a child's profile in such ways, we can more readily guide her toward solutions. Of course, it's also important to try to understand why these particular things are occurring with these particular children. And, incidentally, the approach that seeks to understand a child's unique qualities doesn't preclude using medication, if and when it's medically appropriate for helping a particular child with the processing challenges he faces.

In any case, the more educators and parents can create a profile of the child's singular qualities, the better we can design suitable intervention for him.

Moving Beyond Labels

For several reasons, though, it is often difficult to give up the traditional labeling. One is that having a ready label makes the child's behavior less mysterious or scary. It's not some unknown, terrible disorder but, rather, a known entity about which there are ongoing research, treatments, and, broadly speaking, ready answers. The labels give us the sense that the problem is manageable. And then, too, using a label implies that the disorder itself is responsible for the child's behavior and, therefore, we don't have to look at what's going on around him or her, in the school, in the home, between the parents and the child, because there is a medical reason for it all. Of course, this oversimplifies the nature of the problem and limits the opportunity to do things that could potentially be very helpful.

Also, it is regrettable that applying certain labels considered to be very serious-even close to hopeless-disorders, such as autism and mental retardation, can lead to giving up on a child. These labels should not evoke so gloomy an outlook. If we look at the child in terms of his unique features, we might see avenues that would readily lead to improvements. This warranted optimism is evident in my frequent recommendation of doing Floortime. (See "Floortime" on page 24.)

The term Floortime is simply shorthand for what I've been describing here-a developmental, individualized approach to both diagnosis and intervention. Floortime helps adults build understanding of the child and design interventions based on each child's particular manner of functioning-the way he processes information, sight, sounds, and touch and the way he functions developmentally and interacts with others. The real agenda of Floortime is to encourage an understanding of each child's uniqueness with the goal of encouraging his or her maximum growth.

For all children, but especially children with special challenges, we recommend an active program of interactions at school and at home. The design is always based on each child's individual qualities and developmental level. We find it far more effective than the assignment of ready labels.